Jennifer:
Welcome everyone to this evening's Webinar, Medicine Safety in Disability Care. My name is Jennifer, your RACGP representative for this evening. We are joined by our presenters Chelsea Felkai and Dr David Graham, and our facilitator Dr Tim Senior.
Before we get started, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past, present and emerging. I would like to also acknowledge any Aboriginal and Torres Strait Islander colleagues that may have joined us online this evening.
I am just going to officially introduce our presenters for this evening. Chelsea is a Newcastle based pharmacist currently undertaking a PhD at Newcastle University. She is an accredited consultant pharmacist and has a special interest in medicine used in people with disability. Chelsea contributed to the PSA Medicine Safety Disability Care report and has served as the President of the PSA New South Wales branch committee for the last three years. In this position she has represented pharmacists at the state level to advocate for vaccination expansion, minor ailment services, embedded aged care pharmacists and highlighted medicine related issues facing those with disabilities. So welcome Chelsea.
David is completing a specialty training in general psychiatry with a sub-specialisation of psychotherapy. He has a clinical and research interest in psychopharmacology, veteran and first responder mental health and therapeutic jurisprudence. Welcome David.
And finally, Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health and a Senior Lecturer in General Practice and Indigenous Health at UWS and an RACGP Medical Educator. Welcome Tim.
Tim:
Thank you very much.
Jennifer:
I am just going to hand over to Tim now and he is going to run through our learning objectives.
Tim:
Thank you. Good evening everyone. I hope you all keeping well. I am coming to you from Dharawal Country where I live and work. These are our learning objectives for tonight, which is education speak for what we hope to get out of this evening. So that by the end of this online CPD activity, we should all be able to recognise risks and barriers around medication administration for people with disability, demonstrate an awareness and understanding of strategies to reduce risks and overcome barriers. And we should all be able to demonstrate an awareness of polypharmacy, psychotropic medications and the importance of medication reviews. And so I am going to hand over to Chelsea Felkai to start us off. Thank you very much.
Chelsea:
Thank you for that. I am just going to try to make sure that I can click through. Excellent.
So I just wanted to start by acknowledging the Awabakal Country on which I am based today and introduce you to the start of our session around the disease prevalence in intellectual disability. Approximately one in five Australians has a disability, and a disability can occur at any time in a person's lifetime, or it may be present from birth. And while some disabilities might be obvious, there are a lot as well that may actually be hidden.
We do not have an enormous amount of data about the overall health of people with disabilities, but we know that it is actually much worse than that of the general population. By definition, people with disabilities have to have a health condition or impairment, so a degree of difference in health status is inevitable. However, the difference that is observed extends to areas of health that have no biological connection to the health condition or impairment that is associated with the person’s disability. And more often it actually comes down to the social determinants of health as to this disparity between the general population’s disease state and people with disability and intellectual disability.
So most of the available data is limited to adults. It is usually about people with intellectual disability, which is why I have focused on it in this slide or those with severe or profound disabilities. The evidence that we do have shows that the health of people with disabilities is worse across a range of health outcomes such as obesity, diabetes, rural health and mental health. We have been able to actually see within Australian studies, including this study that was recently published around the potentially preventable hospitalisations of people with intellectual disability in New South Wales, that people with ID have two and a half times more health problems. They have double the use of emergency department admissions, double the number of hospital admissions and five to eight times higher prevalence of acute conditions, which is highest for epilepsy, convulsion and dental. So by that we are looking at things like infections, whether that be fungal, bacterial, viral for the most part and pain issues. And we also see three times more vaccine preventable conditions, which is something that I think we all could strive to do better with when it comes to people with intellectual disability. And we do actually have demonstrated evidence, whether intentional or not, that people with intellectual disability do experience a certain degree of discrimination in hospitals and other health services where we are not able to accommodate for the particular needs of this cohort.
So, I actually have taken part in the development of the Medicine Safety Disability Care, which is one of a suite of disability care documents or reports that the Pharmaceutical Society of Australia has brought out over the last five years. So this is actually our fifth report in our Medicine Safety series and focuses on the challenges that people with disability face in using medicines safely and effectively. And what has been quite interesting about this report is that we have been able to demonstrate that it is across the medication management cycle. People with disability face barriers that many other Australians do not have to face. So those challenges can occur at the prescribing, dispensing, administration adherence and monitoring stages of using medicines.
So just to do a bit of a quick overview of some of the findings from the report. Many people with disability do require complex medical care and the PSA Disability Care report outlined some really significant challenges to safe medicines use within that disability sector. As I mentioned before, it happens at every stage of the medication management cycle and the barriers you can see on the left hand side we have kind of drawn up almost like a road map, so if it was someone with a disability, we are going right through from the being introduced onto a medicine stage, right through to the monitoring and evaluation stage. They will face barriers at every step. So some of those barriers include things like barriers to accessing prescribers, so the ability to actually in some instances even leave their home. And I have had lots of reports from the carers and from the people with disability that I have worked with just talking about how telehealth has completely opened the world of healthcare to people with disability that do find it difficult to leave their houses and particularly those with autism and other sensory issues have found that this makes being able to see their healthcare professionals so much more accessible.
We also see barriers when it comes to inappropriately prescribed medicines and sometimes it is not necessarily about the immediate prescribed medicine at the time, but more the review process and ensuring that at regular intervals a medicine is challenged or reviewed to ensure that that is still the case, that that medicine is still the best option for that person at that point in time. We see the same in terms of accessing pharmacies, and many pharmacies are not built to accommodate people with disability, ensuring that aisles are wide enough and that the heights of benches are built to allow that accessibility.
And of course, we see really huge issues when it comes to accessing information about medicines and understanding what is actually the information in the provision of resources. So understanding not just how to take a medicine, but why they are taking a medicine and what side effects they might be experiencing and understanding those things.
There is also quite a bit of difficulty on taking and using medicines, and many of the people that I do medication reviews with often suffer from difficulties with the actual physical act of taking a medicine. They may have swallowing difficulties or dysphasia to varying degrees, and understanding what can and cannot be done with medicines, not just teaching that to people with a disability but also to the carers and ensuring that they are not crushing tablets that aren't designed to be crushed or that will lose its efficacy or increased side effects if they are crushed. And that seems to be quite a large issue that I see in particularly the group homes that I work in, largely because many of the carers are really fantastic and they do undertake a reasonable amount of training, but they also do not always have that background of being a healthcare professional and do not necessarily understand some of the nuances when it comes to medicine and health.
Even the physical act of getting medicines out of the packaging and barriers to accessing medication management review services, which is really sort of at the heart of some of the things that I do. So the system that the home medicine review model is set up for is really for our general population and does not cater particularly well to people with disability. There are some enablers, however, that we might be able to help to turn this around. So looking at ensuring appropriate use of medicines by conducting those medication reviews and particularly those difficult times such as hospital discharge and transitions of care like those really risky times are super important, particularly because they often get discharged back to a group home again without having anybody like a nurse within an aged care facility that might have a bit more of a clinical understanding or background around the medicines. And particularly looking at the appropriate use of psychotropics which the Royal Commission that looked into disability, that is still ongoing, they have not actually announced their recommendations yet, it has been a few years that it has been going on for, really highlighted the risks of polypharmacy and psychotropic use for people with a disability, just as it did for the aged care setting in the Royal Commission into aged care.
We do need to remove a lot of the barriers in accessing the pharmacy and that means the physical getting to the pharmacy and as I mentioned before within the pharmacy itself, and remove barriers in accessing information about medicines. And that might include things like ensuring that the medicines information is in a digestible format, which often for people with intellectual disability needs to be in a format called Easy Read, which I know David is going to speak a bit more about later.
We also need to remove the barriers in medicine administration. So making sure that even just the way that we package the medicine is going to be more compatible for people such as the use of Braille, which is very much not utilised in the pharmacy setting. A big part that I want to, I guess make sure I articulate today, tonight, is just improving the access to medication management review and those medicine safety services, so how important it is for people with disability to actually be able to have medication reviews conducted and any time is a good time, particularly if anybody is on multiple antipsychotics at any point in time. Like every time they are on multiple anti psychotics, they are at risk. So regular review of those types of medicines is really important and that also leads nicely into improving the monitoring of medicines. And I think across the board, all healthcare professionals probably need a bit more understanding of the NDIS and how it works for our people with disability as well.
So, we had a number of recommendations that came out of that report. We wanted to make sure that disability service providers and by that group of service providers, mostly it is people who are in group homes, so supported independent living. They really do need access to better resources and health help, and access to quality use of medicine services. So we see a lot of the same issues within the aged care sector happening within group homes. However they do not have the same access to the quality use of medicine services. So where a pharmacist might be funded to go in and do education and training to the staff at an aged care facility, nothing like that exists for the disability sector, which means that the disability sector is quite, it is almost like it slips through the gaps when it comes to the medicine services available to other populations. We believe that we need to enable pharmacists to register as NDIS providers and this is to increase the access of people with a disability to those medication management services. And an example of this is, there is a pilot that is occurring at the moment in South Australia where pharmacists, accredited pharmacists, are working with disability behaviour support specialists. So when they are building their positive behaviour support plans, they are often having to sign off on chemical restraint that they do not understand or know anything about. And there is been a little bit of controversy on their behalf and fear that they are signing it off as an endorsement of that chemical restraint when they do not know anything about it. So there is an ability for a pharmacist to be a clinical supervisor to a behaviour support practitioner, when they are actually developing these behaviour support plans to provide education and an overview of the medicines, and that is something that is funded through the NDIS, but we need to be funded as a private sort of provider. There is nothing that exists within the NDIS that is specific to medicines.
We need to allow suitably trained pharmacists to administer vaccines and other injectables to people in the disability setting of their choice. And to a large degree a lot of that actually happened throughout COVID. So pharmacists were able to go to peoples’ homes and be able to administer vaccines within their houses and I myself have administered COVID vaccines to people within the group home, and flu vaccines as well. And I think it is an important thing to acknowledge given that there is such a high prevalence of vaccine preventable diseases that we are still seeing in the disability sector. And we need to actually get a better set of quality indicators around medicine safety for disability care so that we can have that continuous improvement model that we have in the aged care setting.
Okay, so just moving on, I actually have a case study that I wanted to show you to highlight some of the issues that you might come across. This to me is a bit of a standard person with an intellectual disability that I would review their medicines for in a group home. And a lot of this is based on several, a bit of a combination of medication reviews that I have done within group home settings. So in this case study, meet Josh. So I have been given a GP referral for a home medicine review for Josh. Josh is a 21 year old boy with autism. He has a history of behaviours including violent outbursts and property damage. Josh has support from a behaviour support practitioner that I mentioned earlier who is working with him and his support people to improve his emotional regulation and distress tolerance and reduce his aggressive outbursts. So if you have not come across the term behaviour support plan or behaviour support practitioner, these are like a set of plans that are designed for people with disability that exhibit behaviour with the goal to reduce any kind of restrictive practices that might be necessary for that person. And a restrictive practice can look like a number of things. There can be mechanical restraints, such as being tied down physically. There can be environmental restraints, such as the locking of the front door. There can also be chemical restraints, which is what we focus on within the health setting for the most part. And chemical restraints often appear in the form of psychotropics and particularly antipsychotics. Often they will be prn use, and there is a lot of a lot more scrutiny around the use of chemical restraints than there ever has been previously.
So behaviour support plans are designed to use other methods to help to divert behaviour before having to move towards any kind of restraint process. So, I just gave in this slide a bit of a brief medical history. It is sometimes more than what I guess you would often see if you were seeing Josh for the first time. Sometimes these medical histories are quite ad hoc and patchy. But for Josh, he was first diagnosed with developmental delay around the age of two. He was then diagnosed with autism spectrum disorder a few years later and intellectual disability. Around the same time, a number of years after that, he was then diagnosed with Attention Deficit Hyperactivity Disorder. And I want to note here that autism spectrum disorder and ADHD are often seen together. They do not always co-occur, but it is quite common to see someone with autism spectrum disorder also having a diagnosis of ADHD. Quite a number of years later in his teens, Josh then was diagnosed with GORD and then a number of years later anxiety, depression and finally around the same time he was also diagnosed with psychosis. Although he completed his childhood immunisations up to 18 months, subsequent attempts at vaccination have resulted in distress for Josh and have since been abandoned, and this is quite often why we see people in particularly with intellectual disability having much lower vaccination rates than the rest of the population.
I have got in our next slide just the medication list that he is on as well as a few clinical details, and these are the types of things that I will often gather while I am undertaking a medication review. So we know his age is 21. Other things that I might gather are his allergies where in this case in the past when he has had penicillin he came up with an uncomfortable rash. He has a resting pulse of 100 and his blood pressure is 137/70 sitting. You can note his height and weight there and his BMI is 31. Importantly, and this is the type of thing that you do not always see noted in other medication reviews, is his communication style. So it is really important that I understand and that I also convey in my reports how Josh likes to be communicated with and who I can talk to in order to be able to then talk with Josh. It is so important that we are talking to the patient themselves, even if that is via a carer. So in this case, and when doing a medication review with Josh, I would be asking Josh the questions if he was happy to sit with me during a medication review and have his carer nearby, who might be either helping Josh to answer the questions, or if he is nonverbal, then some of it would be answered for him by his carer, but ensuring that he is part of that communication all around.
So there are a number of challenges in treating patients with autism spectrum disorder and intellectual disability. So I have mentioned that communication, some intellectual disabilities and ASD can result in poor speech and language skills. It can be really difficult to differentiate the clinical features of ASD from the symptoms of emerging or current mental illness. So sometimes we see this comorbidity that occurs and it is really important when making a new diagnosis that it is based on a sort of repeated pattern and that it is been differentiated from the features of their original diagnosis. Determining a treatment plan that addresses very challenging symptoms such as aggression, agitation, impulsivity, and obsessions. It is incredibly complex. And as you can see from this medication list, this is not unusual for someone like Josh to see this sort of type of medications. In fact, I would even go so far, and it is probably due to his age that his medication regime is far less complex than some that I have seen that are much older.
But avoiding polypharmacy where possible is really important. And basing our recommendations on evidence is also enormously important, while also treating a range of mental illnesses. So you can see where it can become a really hazardous sort of area where you are trying to treat because it is important to treat the symptoms and to manage the person’s distress and also the distress and well-being of the rest of the family, but while also avoiding the negative impact that medicines can have on an individual. And many of the drugs prescribed in autism spectrum disorder, this is sort of the icing on the cake. They have really limited supporting evidence and some have significant adverse effects. So monitoring is critical when it comes to medicines use for autism spectrum disorder and intellectual disability more broadly.
So I have here that he is on chlorpromazine. He is actually using 150 milligrams twice a day. He is on risperidone, 2 milligrams twice a day, the atomoxetine 40 milligrams twice a day, esomeprazole 20 milligrams, nice maintenance dose, and paracetamol when required, hydrocortisone to the affected area, so it would be interesting to know what it is that he is having to use that for, and Lactulose for constipation because that constipation and GORD tend to be like the most common coexisting conditions that people with intellectual disability will have, and it really largely comes down to the medications that they are taking and the side effects due to them, because antipsychotics can and will cause constipation and reflux.
So, there is a number of sort of medication related issues that can be identified from this review. And this is quite complex and I have intentionally not sort of provided any what you would call like answers because there is not any kind of correct answers when it comes to a medication review like this. This is all about looking at the history of what he has tried up until this point. Ensuring that the medicines are safe and appropriate for him at this point in time. But some questions that I might have when I was looking at Josh would be things like what is his mood currently like? So if he has quite labile mood, if he tends to be, you know, as was outlined at the beginning, his behaviours could be quite difficult to manage and he can sort of fly off the handle so to speak, quite quickly and easily, then it might be something that we need to address as a priority for him and the family if that is being active right now. And it is also important to note that many, many people of Josh's age and with the conditions that he is currently suffering with, will often have other mental health conditions. So anxiety is an example. It is a really common comorbidity and interestingly, the atomoxetine is often used in patients with ADHD with comorbid anxiety. So it may be that the atomoxetine, although it has relatively limited evidence, it is one of the few that we do see for ADHD. It is preferred for people who also have comorbid anxiety. While cognitive behavioural therapy can be effective in some cases, we may need to use an SSRI. But we would also have to be mindful that with this combination of medications, we also would need to be monitoring for serotonin syndrome.
So as I mentioned with the labile mood, sorry, I will continue with the missing therapies. So I noted before that his vaccination status is probably not up to scratch and that we need to improve that. So we would be looking at how we can ensure that maybe his environment needs to be comfortable because he responded negatively to vaccines in the past does not mean that we should not continue to try to improve his vaccination status moving forward. And it might take several attempts, with different things, within our arsenal, to try and make sure that he is feeling safe and comfortable. Before we actually are successful with providing a vaccination, but once we work out what works, we can then replicate that and ensure that we can get his vaccinations up to date.
When we are looking at the labile mood, children with autism spectrum disorder who present with those types of externalising behaviours targeted towards the external environment such as physical aggression, threats, destroying property, they often have a labile mood and they also often have learning disorders. They have poor self-regulation and behavioural problems at school and because of all of this, that is why I mentioned that it is worthwhile asking the question about how his anxiety and other mental health conditions are, because this all contributes to their sense of self as well. So risperidone is approved by the TGA for irritability and aggression in autism in patients under the age of 18. However, there are risks, just as with all other medicines. But the risks when it comes to risperidone include often weight gain, elevated lipids, blood glucose and prolactin, and it does actually cause an interruption of puberty. And risperidone is not quite as problematic with its cardiometabolic effects as some other antipsychotics are out there, so it may be the most appropriate choice for Josh at this point in time. The interesting one I found here was the chlorpromazine. So although it is indicated for severe behavioural disturbance in children, it is rarely used. The risk of respiratory failure particularly, and that is largely in combination with other sedating medicines, makes this a really tricky medicine to use for people, especially as a secondary antipsychotic. It also has a really photosensitising effect and if Josh is someone who enjoys spending time outside, then chlorpromazine is potentially not the right medicine for him. Sodium valproate can be helpful with aggression. It is also used to treat irritability and mood lability. However, with other mood stabilisers, there is not a lot of data that we can go off. So while sodium valproate has a lot of adverse effects, including nausea, poor attention, skin reactions, it is one of the few that actually does have some evidence with aggression.
When we are looking at multiple antipsychotic use, the general rule of thumb is that it is really not recommended. There is limited evidence and there is a high risk of adverse effects. So it really needs to come right at the end of having exhausted pretty well all your other options. And not only that, but it should be reviewed quite strongly again and again at regular points. We need to make note that it contributes to temperature dysregulation and increases the risk of EPSE and cardiometabolic effects. So the monitoring I have put there includes the cardiac effects, bowel management plan. He has clearly got some issues there, given the Lactulose and the monitoring for antipsychotics.
So finally, I just wanted to make note that there is the Home Medicine Review program and this is just a reminder of the process that it undertakes. I will not take you through it, but just that the eligibility criteria is that anyone living in a community setting that is at risk of experiencing medication misadventure, it is appropriate to provide a referral for an HMR service. And as a pharmacist, we are allowed to do it every two years or where review is clinically necessary and that would include for example, if someone were discharged from a hospital setting or had new medicines that they were undertaking. So that was all from me and I think that I can pass it over now to David.
David:
I am hoping everyone can hear me. I am talking tonight from Ku-ring-gai Country and just going to talk a little bit about communication and various other sorts of issues particularly the issues of consent as well as capacity that goes with that as well, and you know the problems associated with de-prescribing. So I do not think I am sort of providing any sort of ground-breaking information here by saying that essentially, you know, when you are working with someone with a disability of any sort, there is additional complexity associated with that largely due to the extent of the supports that are in place or should be in place.
The communicating with people with disability. And again I just want to caveat this particular slide by, you know, noting that you should really take the patient into account and always consider who you are talking to. Now, after all, a really sharp elite soldier who has lost the use of his legs due to a military related incident is going to be able to handle very long words and complex sentences and you know, to be honest, in my experience, they may even run rings around you. So you know, really what this particular slide about communication is to match your style to your audience. After all, communication does involve, you know, a message, how the message is conveyed, who is conveying the message and who is receiving it, the environments you know, where you are located, the context. So that that would include things like, you know, that particular topics that you are talking about, the types of messages you do want to discuss. Any interferences that might be occurring, so if there is a young child or something like that, and to actually get some feedback from the person who is receiving the message as well to make sure that it has been sort of taken on board.
And so fundamental to a lot of the decision making is capacity, and that is where communication really shines through. And you know, capacity is really about whether someone has got the cognitive ability to understand, you know, the nature and effects of ones acts. And that is very different from competence, which is about being qualified. And so you cannot presume that a person lacks capacity if they decide to pursue a course that is against medical advice. And I cannot tell you the number of times that I have seen this particular issue in a consultation liaison role where a medical team would be proposing one particular course of action and a patient might refuse. And so the presumption is that, well, now we have to check their capacity. The reality is we need to assess the capacity the whole way through that we are providing treatment. You know, it is fundamental to what we do as doctors and you know, ultimately a psychiatric assessment is not required for that particular assessment. After all capacity itself, you know, a person is assessed to have capacity if they can personally understand the information that is being given to them about whatever treatment proposal is being made, that they can remember the information that is being given, that they can weigh up the risks and benefits associated with the treatment and that they can communicate their choice. And so for instance, if you have the patient who has chronic schizophrenia and believes that they are Napoleon Bonaparte, that does not necessarily mean they do not have capacity, if they can convey all of those different aspects of capacity. So really the question of whether somebody has capacity depends on the situation. Someone may have capacity for a very simple decision, whereas they may not have capacity for a much more complex decision.
If you find that they do lack capacity then that is when the legal guardian can step in to make a decision. But if there is no guardian in place then an application needs to be made through the New South Wales Civil Administration Tribunal, and there are similar tribunals throughout in other jurisdictions as well, and they can appoint a guardian on your behalf or on the patient’s behalf. And I should also stress as well and this is a very important legal question, is that there are limits to the decisions that a guardian can make on behalf of a person. And you can see a few of the situations where only NCAT can make a decision and it is basically the same issues in other jurisdictions as well.
So, you know, when we are talking to a person with a disability, again making reasonable adjustments to really enhance the possibility for the message to get across. One of the little points there is the Teach Back method which is essentially another way you can really check their capacity. So you tell the person what it is that you want to talk about, ask them whether they understand, listen to their response. And then repeat the message if they if they do not understand. As I said, that is the crucial component to capacity. So thinking in the back of your mind about whether they have capacity to make a particular decision that you are talking about is something that you can continually be doing.
There we go. Okay, so a big question, and I think this case that Chelsea very skilfully presented about Josh is that it raises a lot of questions about polypharmacy and the need to potentially consider de-prescribing. And that is an issue that needs to be considered very, very carefully. I mean after all he is reported to have a psychotic illness, but there is no real details about which particular psychotic illness it is. Was it a brief psychosis, was it is stress related? After all, a lot of autistic people do have higher rates of PTSD. And what we do see a lot in PTSD is brief psychosis that can be triggered off by very stressful events. And so we need to really understand well, what is the purpose of the particular medications that he is on? You know, it is worth considering that the anti-psychotics that he is on are appropriate for a psychotic illness. But chlorpromazine is you know, incredibly sedating. It is the original antipsychotic, incredibly sedating medication, and has increased likelihood of anticholinergic side effects. And all of that together is going to reduce his sensorium and that may in particular contribute to any autistic meltdowns that may be happening. So what you can effectively be doing is while on the one hand maybe chlorpromazine was originally prescribed prn to help reduce any potential harm to himself or others, ultimately what it is going to do is, it is going to reduce that sensorium and particularly given his vulnerable substrate, his brain is very vulnerable. It is nice to see that risperidone is there. It is an atypical antipsychotic and atypical antipsychotics do have antidepressant effects at low doses. And so that may actually help to engage his frontal lobes, which can help him regulate his emotions a little bit better.
One of the things that Chelsea mentioned was about the combination of effects and it is really important to consider that Strattera increases the risk of arrhythmias when it is used with either chlorpromazine or risperidone. So whether or not it does have some sort of antidepressant effect for Josh, at the end of the day you are increasing his risk of potentially lethal cardiac events.
I want to sort of pull back a little bit by highlighting that, you know, just with autism generally, that low doses of risperidone or aripiprazole can actually be used to help them to engage in therapy. So things like behaviour support plans. But what we do also know is that when you do cease the risperidone in particular, then there can be a discontinuation effect and so a rapid return of disruptive and aggressive behaviour. So you are kind of stuck between a bit of a rock and a hard place. While you might want to use something like haloperidol or risperidone prn to help with harm against him himself or other people, using a single agent is generally preferred, but dual antipsychotics can actually be used in certain circumstances and that is supported by the College of Psychiatrists guidelines, and in practice, psychiatrists do often use dual antipsychotics, you know, to help with things like hyperprolactinemia which you might see with somebody who is on risperidone or paliperidone. And so ultimately the question of de-prescribing really comes down to the rationale for why you want to de- prescribe. So for instance a patient who has very well controlled schizophrenia after one to two years you might consider reducing or ceasing that particular medication, but they also have an increased risk of a relapse. So really when you are talking about de-prescribing antipsychotics then a psychiatrist will probably need to be involved.
So there are various different strategies and Chelsea has talked a little bit about the item 900 and there are various other MBS items which can be used to manage somebody as complex as Josh. But I also want to sort of give a plug for my own fellow colleagues, that there is a GP psychiatry support line and I understand that we may be being streamed around the nation tonight, but that number is available to anybody across Australia. I think they only work 9:00 to 5:00 which is very nice, and you can always reach out to them for some quick advice on antipsychotics or antidepressants. But if you do have someone as complex as Josh I would also encourage you to try to make a referral for a psychiatric review and MBS item 289 is specifically for somebody like this young fellow. It is used for people who are under 25 who do have complex neurodevelopmental problems like Josh. 291 and 293 are other MBS items that can be used where a psychiatrist can give a proper medication review to provide support, a detailed management plan, to a GP to take over their care. I think that is it from me. I want it to be as quick as possible, being aware of the time. And Tim, that gives us about 10 minutes for questions.
Tim:
Yes. Thank you very much. So these are our learning objectives again and so while those are up on the screen, and I can even read them out to you, if you do have any questions, we have definitely got time for answering them if you want to type those into your Q and A box now. I will read out the learning objectives while you get typing. So hopefully by now and by the end of questions, we should all be able to recognise the risks and barriers around medication administration for people with a disability. We should be able to demonstrate an awareness and understanding of strategies to reduce risks and overcome barriers, and demonstrate an awareness of polypharmacy, psychotropic medications and the importance of medication reviews. My feeling is certainly that we have covered that. It always strikes me that so much of the work that we do in general practice is really complex, there is a lot of issues, and as Chelsea was saying, there is no right or wrong answer, and I think that sort of team based care involving pharmacists working together and involving psychiatrists and that psychiatry helpline are going to be really important in doing this.
So we have got a question here, important one I think. To determine patient capacity, is it better to refer to psychiatrists to assess? David, what would be your comments on that?
David:
My comment is essentially as I said, that it is not necessary to refer to a psychiatrist. Any medical practitioner can make a capacity assessment. As I mentioned before, the four elements of assessing capacity are that firstly do they understand the information that you have provided to them? Can they remember the information that you have provided to them? Can they demonstrate that they are weighing up the pros and cons associated with what you are proposing? And finally that they can communicate that choice? This is something that, you know, people in the emergency department do routinely. A psychiatrist is not necessary to be called in to do that particular task. And I also want to acknowledge that it is incredibly difficult to refer somebody to a psychiatrist these days. So it would be a very difficult situation if you are entirely relying on a psychiatrist to do that particular assessment.
Tim:
Yes. And I think what I will add to that is the position we have is GPs we very often and if we are lucky enough, we have got a relationship with the patient already. So actually we have got a lot of information about the way that people are going about decision making and assessing information, before we have actually seen them with regards to that particular decision. And certainly that for me has been really helpful in saying yes, this person actually is quite able to make these decisions, because I have seen them make those sorts of decisions, and weigh up that sort of information before.
And I think as Marian says, there was a link in the slides to the New South Wales Health Consent Manual which may be a helpful tool for going through with patients, to guide us on ways of making sure that the patient is able to consent to particular procedures. A question and a comment, the comment is exactly what David is just saying, in the real world, meaningful psychiatry referrals are almost impossible, which I think is why that psychiatry helpline is going to be really useful for us I think.
Generally speaking, should SSRI and or valproate be trialled before the use of an antipsychotic?
David:
I think it depends on the situation. So it depends on what you are trying to treat as to whether you will be going with an antipsychotic, SSRI or an antiepileptic. So if you are working with somebody with depression and anxiety, then obviously an SSRI is going to be your first line choice. Ann antipsychotic is going to be your first line choice for a psychotic illness. Using valproate, again very useful for someone with a bipolar illness, but can be used to augment for treatment resistant depression as well as some psychotic illnesses. Antipsychotics can also be used to augment depression and anxiety. So really it depends on the situation as to which one you trial first. It is hard to say Richard from your question about particularly which condition you might be thinking about those different medications for, but I think at the end of the day the overall guidance to that is that diagnosis guides treatment, is going to be where your answer lies.
Jennifer:
Perfect. Thank you.
Well, it does not look like there is any other questions, so we will wrap it up. I would like to extend my thanks to Chelsea, David and Tim for presenting this evening. And I would also like to thank everyone who has joined us online. We do hope you enjoyed the session and you also enjoy the rest of your evening.